Distinguishing Consultation from Comanagement, Referral, and Collaboration*

Four terms with similar meaning are often used interchangeably; each term suggests specific relationships and responsibilities. The subtle differences between the terms consultation, comanagement, collaboration, and referral are identified when one examines the degree to which an APN assumes responsibility for the direct management of a clinical or administrative problem.

Consultation is an interaction between two professionals in which the consultant is recognized as having specialized expertise (Caplan, 1970; Caplan & Caplan, 1993). The consultee requests the assistance of that expert in handling a problem that he or she recognizes as falling within the expertise of the consultant. Consultation is a role function used by APNs to offer clinical expertise to other colleagues, as a specialty consultant, or to seek additional information to enhance their own practice. Given APNs’ advanced knowledge and assessment skills, and in some cases expansion of the APN role into areas of specialization, consultation for peer APN expertise can foster improved accessibility, consultation, and timely and potentially improved care for patients waiting to be seen for patients with unique conditions.

Comanagement is the process whereby one professional manages some aspects of a patient’s care while another professional manages other aspects of the same patient’s care. Effective comanagement requires excellent communication, coordination, and collaborative skills. Professionals who work within the same interdisciplinary team often develop systems that facilitate seamless and effective comanagement. In comanagement, both providers retain responsibility for the patient’s care (Table 9-1).

APNs are often confused in practice between consultation and collaboration. Chapter 12 provides a thoughtful definition of collaboration that was first offered by Hanson and Spross in 1996: “Collaboration is a dynamic, interpersonal process in which two or more individuals make a commitment to each other to interact authentically and constructively to solve problems and to learn from each other in order to accomplish identified goals, purposes, or outcomes. The individuals recognize and articulate the shared values that make this commitment possible.” Collaboration is a process that underlies the professional interactions involved in consultation, comanagement, and referral. Whatever the nature of the consulting relationship, the APN keeps the patient at the center of her or his actions; therefore, consultation requires collaboration on some level when two professionals come together to meet patient-centered goals. Recruiting other professionals for collaboration organizes support of an interdisciplinary group, thereby increasing the impact on the patient or problem through the synergy of multiple experts. An example of collaboration may involve a geriatric clinical nurse specialist (CNS) and palliative care nurse practitioner (NP) participating in a family meeting to discuss goals of care with a frail older patient and his or her family regarding end-of-life wishes, including code status and hospice.

A referral describes a situation in which a clinician relinquishes responsibility for care (or aspects of care), temporarily or permanently, to another clinician who is likely a specialist for an opinion or management of part of a patient’s care. In most cases, once the care associated with the referral is complete, the patient will return to the full-time care of the referring clinician.

Consultation occurs when the APN requests the advice or opinion of a physician or other health care team member and the APN maintains primary responsibility for the patient’s care. The ACNM uses the term collaboration to describe the process whereby the CNM and physician jointly manage the care of the woman or newborn. Another frequently encountered term, referral, describes a situation in which the clinician making the referral relinquishes responsibility for care (or aspects of care), temporarily or permanently.

Types of Consultation

According to Caplan’s classic definition (1970), there are four different types of consultation. Client-centered case consultation is the most common type of consultation. The primary goal of this type of consultation is assisting the consultee to develop an effective plan of care for a patient who has a particularly difficult, complex, or unique problem. In client-centered case consultation, the consultant often sees the patient directly to complete an assessment of the patient and to make recommendations to the consultee for the consultee’s management of the case. This is often a one-time evaluation, although follow-up by the consultant is sometimes needed. The primary goal is to assist the consultee in helping the patient. A positive experience when handling that specific case will enhance the consultee’s ability so that future patients with similar problems can be treated more effectively. For example, the APN may consult an infectious disease APN to elicit her or his opinion on an ongoing infection in a human immunodeficiency virus (HIV)–positive patient. This consultation would be specific to the clinical problem at hand and result in recommendations for the consultee to manage or comanage a challenging clinical infection with the assistance of an expert infectious disease APN. The recommendations could include information such as which antibiotics are recommended to treat the infection, how to monitor response to the antibiotics, and potential adverse effects of the treatment plan.

In consultee-centered case consultation, improving patient care is important but the emphasis is focused directly on the consultee’s ability to handle a challenging situation. Thus, the primary goals are to assess the consultee’s needs and address the problem effectively. In consultee-centered case consultation, the task for the consultant is to understand and remedy the problems of the consultee in managing a particular case. A usual problem is lack of knowledge, skill, confidence, or objectivity. Therefore, the consultant may educate the consultee further on the issues presented by the patient or may suggest alternative strategies for dealing with the problem. This is probably the most common type of consultation sought by APNs. The consultant may seek to bolster the confidence of the consultee in handling the problem if, in the opinion of the consultant, the consultee has the ability and potential to do so. If the problem presented by the consultee is a lack of professional objectivity, the consultant can help the consultee identify the factors interfering with the consultee’s ability to see the patient realistically. The consultee may hold a stereotyped view of the patient, or perhaps the patient’s difficulties in some way mirror or symbolize the consultee’s personal difficulties and cloud the consultee’s ability to see the reality of the situation.

Effective consultation can foster orderly reflection and extend the frames of reference used by the consultee to solve clinical problems (Caplan & Caplan, 1993). Both client-centered and consultee-centered case consultations have been important activities in traditional CNS practice. For example, the psychiatric CNS is often consulted by the APN in the hospitalist role who has patients with advanced dementia, behavioral disorders, or long-standing psychiatric diagnoses that may need adjustment now that the patient has been hospitalized. Although the APN hospitalist is comfortable with behavioral assessment and continuity of care, he or she may not be adept at treating the changes in behavior that can occur while the patient is hospitalized. The psychiatric CNS can apply specific knowledge, along with the necessary medical treatment, to maximize patient care while she or he is hospitalized and teach the APN these diagnostic and management techniques. In the primary care setting, this type of consultation can be seen when APNs confer with their physician or APN colleagues to confirm their differential diagnoses or individualize a treatment plan.

Program-centered administrative consultation focuses on the planning and administration of clinical services whereby the APN consultant steps in to offer needed clinical expertise in a clinical program focused on a patient population. Consultee-centered administrative consultation focuses on the consultee’s (or group of consultees’) difficulties as they interface with the organization’s objectives. For example, an APN may consult with a group of administrators who want to implement a clinical service, such as wound care or breast health. To assist in the development of these two programs, the APN’s consultation can offer perspective on how specific needs—both clinical and psychosocial—of these two patient populations can be met.

APNs may be involved in all four types of consultation at various times. This chapter specifically considers the first two types of consultation, client-centered case consultation and consultee-centered case consultation, because the focus here is the process of interacting with other professionals regarding the care of individual patients. Case consultation can bridge the gap between evidence or knowledge and practice, assisting staff in improving care for patients and families through broadening perspectives, expanding expertise, and generalizing knowledge appropriately (Lewandowski & Adamle, 2009).

Consultation and Specific Advanced Practice Nurse Roles

The consultation competency has received significant attention in the four APN roles and is explicitly addressed as a role expectation (AACN, 2006; 2011; American Association of Nurse Anesthetists [AANA], 2005; ACNM, 2011, 2012; National Association of Clinical Nurse Specialists (NACNS), 2004; National CNS Task Force, 2010; National Organization of Nurse Practitioner Faculties [NONPF], 2011). Although all APNs seek and provide consultation, the literature on consultation in specific APN roles varies. Certified nurse-midwives (CNMs), for example, specifically address consultation as an expectation (ACNM, 2011). In addition, consultation has long been a specific expectation for those in CNS positions. Consultation as a competency is less frequently addressed in the certified registered nurse anesthetist (CRNA) and NP literature, although they are likely to consult and be consulted formally and informally in practice on a regular basis.

Of the four APN roles, the CNS literature contains the largest amount of information regarding consultation. As a CNS, the professional focus remains on clinical nursing, although the CNS also spends time in nursing staff education, evidence-based practice, and system change and innovation. As a clinical expert, a CNS hones consultant-consultee relationships with the nurses who provide bedside care in the acute setting (Dias, 2010). In these consultant-consultee interactions, the CNS can influence patient outcomes by modeling and leading nurses to use evidence in making clinical decisions. For example, a CNS may discuss the chemotherapy care plan or wound care protocol with the staff nurse prior to implementation to ensure that the nurse has a complete understanding of the interventions to be provided.

In the CNM role, managing patient risk and responding to the patient’s best interest drives the decision to refer for an obstetric consultation (Skinner & Foureur, 2010). In New Zealand, the obstetric consultation rate is 35%. Although the consultation rate may seem high, the reasons for consultation were significantly justified and the midwives usually continued to provide some midwifery care for the patients, even when risk had been identified. The consultation with the obstetrician did not automatically result in comanagement of the pregnant patient by the physician and CNM; rather, most patients returned to the care of the midwife with the consultant’s input (Skinner & Foureur, 2010).

Some examples of NPs as consultants have been described in the literature. The development of mental health NP consultant liaisons who consult on emergency department (ED) patients has been explored in Australia (Wand & Fisher, 2006; Van Der Watt, 2010). These NPs consult with ER colleagues on patients with behavioral issues who present to the ED using therapeutic techniques and medications for acute crises, and making referrals, as needed. These roles have been shown to increase collaboration and improve patient and family satisfaction and are seen as complementary to rather than a replacement for medical psychiatric care (Wand & Fisher, 2006). Other examples of NP consultation have been illustrated—NP-led rapid response teams demonstrate decreases in need for cardiopulmonary resuscitation while providing patient treatment and staff education (Benson et al., 2008), and NPs in interventional radiology provide consultation related to vascular access and diagnostic procedures (Dryer, 2006).

• The consultation is usually initiated by the consultee.

• The relationship between the consultant and consultee is nonhierarchical and collaborative.

• The consultant always considers contextual factors when responding to the request for consultation.

• The consultant has no direct authority for managing patient care.

• The consultant does not prescribe, but makes recommendations.

• The consultee is free to accept or reject the recommendations of the consultant.

• The consultation should be documented.

Ecologic Field of the Consultation Process

APNs tend to have a holistic orientation and understanding of systems theory that enables them to apply this consultation model in practice. At the center of Barron and White’s (1996) proposed model are the purposes and outcomes of consultation. Surrounding the center is the ecologic field of the consultation. Consultations are embedded in the context of the specific circumstances surrounding the consultation request, so the ecologic field in which the consultation takes place must be understood to provide effective consultation (Caplan & Caplan, 1993). This involves an appreciation of the interconnection and interrelatedness of the systems and contexts influencing the consultation problem and process. Thus, the consultation process is an integral part of the ecologic field. The process—in which the consultant evaluates the request, performs an assessment, determines the skills required to address the problem, intervenes, and evaluates the outcome—is expanded in Figure 9-2. Other elements of the ecologic field include the characteristics of the consultant, consultee, patient and family, and situational factors. We assume that there are reciprocal influences among the purposes, process, and contextual factors that can affect consultation processes and outcomes. Each component of the model is elaborated in the following sections.

Purposes and Outcomes

The purpose of a consultation may be to improve care delivery processes and patient outcomes, enhance health care delivery systems, extend the knowledge available to solve clinical problems, foster the ongoing professional development of the consultee, or a combination of these goals. Consultants should be aware that the purposes for which they have been consulted may contract or expand during the process of consulting. Often, APN consultants accomplish several purposes at once. If additional purposes and possible outcomes are uncovered during consultation, these should be made clear to the consultee. The consultee may want the consultant’s assistance with a patient but does not have the time or interest to focus on his or her own development. Patients may also reveal information that requires a shift in the consultation’s focus, purpose, and outcome. Over the course of the consultation, being explicit about the goal or outcome of the consultation is essential if APNs are to evaluate the impact of consultation on practice.

Consultation Process for Formal Consultation

Figure 9-2 presents an algorithm of the consultation process. With experience and expertise, the process may occur fairly rapidly so that the expert consultant may not be consciously aware of using these steps. In addition, in some situations, the problem for which help is sought is clear-cut and the consultation is brief. These types of consultations are discussed later in the chapter.

Once a request for consultation has been received, assessment of the consultation problem begins with evaluation of the request itself. An important component of assessment is confirming with the consultee that consultation is, in fact, the appropriate strategy for addressing the problem (e.g., rather than a referral). At this stage, the consultant and consultee may decide that an alternative process is needed (e.g., a shift to comanagement or referral). The consultant confirms that the problem has been accurately identified and falls within the realm of the consultant’s expertise and clarifies the nonhierarchical nature of the relationship between the consultant and consultee. The consultant also confirms that the consultee will remain clinically responsible for the patient who is the focus of the consultation. The consultant must remember that the consultee is ultimately free to accept or reject her or his recommendations. Once the request itself has been considered, the consultant gathers information from the consultee about the specific nature of the problem. The consultant tries to determine whether the patient has unusually difficult and complex problems (patient-centered consultation) and whether the problem results from the consultee’s lack of knowledge, skill, confidence, or objectivity (consultee-centered consultation). Once the request, the nature of the relationship, and appropriateness of consultation have been established, the consultant focuses on gathering data related to the consultation problem. This may include direct assessment of the patient. The consultant considers the ecologic field of the consultation, which includes the systems and contexts that may influence the patient and family, consultee and staff, and setting in which the consultation takes place. Some requests for consultation are focused and require that the consultant identify aspects of the ecologic field that are priorities for assessment and attention. Others require more comprehensive assessment.

The consultant uses available resources such as patient records, direct assessment of the patient, and interviews with staff and family to identify the exact problem(s) that is (are) to be the focus of consultation. This may or may not be the problem for which help has been sought. Some consultation problems are simple and do not require extensive data collection. Others are complex and may require extensive chart review for a long-standing problem or calls to referring clinicians when incomplete data have been provided. The consultant shares the identified problem with the consultee and validates this with the consultee. If part of the problem is the consultee’s lack of expertise, the consultant will want to use tact as the problem is identified and discussed. Interpersonal qualities of the consultant are crucial (see later).

Once the specific problem or problems have been identified, the consultant and consultee consider interventions that will address the problem(s). The consultant may intervene directly with the consultee by using approaches such as education, assistance with reinterpretation of the problem, or identification of appropriate resources if the problem is the consultee’s lack of experience. If the problem results from a particularly difficult patient situation, the consultant may assist with the process of clinical decision making by providing alternative perspectives on the problem and recommending specific interventions. More data may be needed to analyze the situation further, and a decision may need to be made about whether the consultee or consultant will gather more data. If the consultee accepts the recommendations of the consultant, together they negotiate how the interventions will be carried out, and by whom. If the consultant is to intervene directly with the patient, the consultee must understand his or her ongoing responsibility for the patient and agree to the consultant’s interventions. Together, they identify additional resources and determine the time frame for the consultation (one time or ongoing).

After the intervention, the consultant and consultee engage in evaluation. Evaluation of the success or lack of success of the intervention and overall consultation is essential to the consultation process. If the problem is resolved, evaluation offers an opportunity for review, confirmation of the enhanced effectiveness of the consultee in managing the problem (underscoring the new skills and abilities or understanding of the situation by the consultee), and closure. If problems remain, reassessment offers the consultant and consultee another opportunity for problem solving.

The process of consultation described is comprehensive and formal. The consultant brings clinical expertise and an understanding and appreciation of the process of consultation to the problem presented. According to the model, the consultant considers all elements of the nursing process in relation to the consultation problem. However, what about the quick questions to the consultant, when what is needed is a piece of information and a brief description of how to apply the information? Are these brief interactions, sometimes called “corridor consultations,” related to circumscribed problems true consultations? They are, absolutely, but the consultant needs to make a conscious decision about responding briefly and simply to the request and needs to consider with the consultee whether the quick response addresses the problem. Sometimes, the problem presented oversimplifies a complex concern, requiring a more comprehensive approach. If the consultant and consultee consider the problem together, they can determine whether the quick response is adequate or whether consultation is needed. Conversely, sometimes what is truly needed is a short answer to a clinical question or validation that the approach to the problem is appropriate.

Staff nurses sometimes equate this brief type of consultation with consultation in general because they have experienced only this type of consultation with physicians, who quickly impart information and are then off to the next patient. The idea of the roving clinical expert dropping by with tidbits of expert advice is the idea that non-APNs can have of a consultant. This is another reason why it is important to make a conscious decision about responding in a brief way to the consultation request. In the informal situation, the consultee may not realize that a more comprehensive and thorough investigation of the problem and solutions with the consultant is possible. Also, some clinical situations require a more formal approach to the consultation problem. APNs should consider the types of problems in practice that require a formal approach and develop a system for integrating nurse-nurse and interdisciplinary consultations, which make advanced practice nursing skills more visible and extend their knowledge and skills.

Stay updated, free articles. Join our Telegram channel

Join